J Cerebrovasc Endovasc Neurosurg.  2022 Jun;24(2):160-165. 10.7461/jcen.2021.E2021.07.003.

Acute cerebral infarction combined with a thyroid storm in a patient with both Moyamoya syndrome and Graves’ disease

Affiliations
  • 1Department of Neurosurgery, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Korea

Abstract

Moyamoya syndrome (MMS) associated with hyperthyroidism, such as Graves’ disease, is a rare condition that causes ischemic stroke with thyrotoxicity. A 43-year-old woman with symptoms of right hemiparesis was admitted. Brain magnetic resonance imaging revealed a small cerebral infarction in the left frontal lobe. Cerebral angiography revealed multi-vessel intracranial occlusive disease. Several days later, neurologic deterioration and aggravation of cerebral infarction developed due to a thyroid storm. A thyroid function test revealed the following: thyroid-stimulating hormone (TSH) <0.01 μunits/mL (reference range, 0.55–4.78 μunits/mL); triiodo-thyronine >8.0 ng/mL (reference range, 0.77–1.81 ng/mL); free thyroxine (T4) of 9.47 pmol/L (reference range, 11.4–22.6 pmol/L); and TSH receptor antibody of 37.10 U/L (reference range, 0–10 U/L). For thyroid storm management, we initiated treatment with methimazole, Gemstein’s solution, and hydrocortisone. Finally, the thyroid disease was controlled, and neurologic deficits improved. We describe a case of acute cerebral infarction combined with a thyroid storm in a patient with Moyamoya syndrome and Graves’ disease. Hyperthyroidism such as Graves’ disease should be considered in the differential diagnosis for patho-etiologic mechanisms associated with MMS. A cerebrovascular disease with a thyroid storm can lead to severe mortality and morbidity. Prompt diagnosis and strict treatment are important.

Keyword

Moyamoya Syndrome; Graves’ Disease; Cerebral Infarction; Thyroid Storm

Figure

  • Fig. 1. Brain magnetic resonance imaging. (A) initial diffusion image, (B) aggravated diffusion image. Cerebral infarction territory at both frontal lobes was increased.

  • Fig. 2. Cerebral angiography. (A) Right internal cerebral artery (ICA), (B) Left ICA, (C) Left vertebral artery. Steno-occlusion of bilateral distal ICA with moyamoya vessels.


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